Facing the puzzling urge to injure

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A Swiss army knife was her tool of choice, but when that was not available — when, for instance, she was hospitalized for depression — Julie would use what she could find; paper clips, staples, screws, or plastic knives.

Julie, a 35-year-old nursing student in Massachusetts, has grappled with the urge to cut herself for half her life. Therapy held the urge at bay for seven years, only to have it slither back in 2006, during a wrenching breakup with her boyfriend.

“The cutting makes me calmer, or it enables me to feel emotion and that makes me calmer,” said Julie, who asked that her last name not be used to protect her identity.

She cut places on her body that didn’t show — on her thighs and stomach — but has not cut herself for eight months, after trying a different type of therapy. “It’s an addiction,” she said. “Those urges dissipate over time, but they don’t go away.”

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Some secretly slice their thighs with scissors. Others repeatedly scratch their wrists until they draw blood. And there are those who chronically punch themselves. For many who wince at a paper cut, the thought of picking up a knife, and intentionally slicing a thigh or arm, seems unimaginable.

But mental health specialists say they are increasingly encountering young patients, including children, who cut, punch, burn, and find other ways to hurt themselves in a desperate attempt to cope with stress, anxiety, and depression.

It’s difficult to pinpoint just how widespread the behavior of self-injury is. It’s not tracked by health officials, and rates of self-harm revealed through research vary widely. Estimates of prevalence in the general US population range from about 2 to 6 percent, while findings among high school students have pegged it much higher, between 13 and 25 percent. A recent study found that roughly 15 percent of college students surveyed admitted engaging in the behavior at some point in their lives.

“There are more than 10 child therapists in our center and we’ve all seen at least one or two in the past year,” said Brooke Rosing, a licensed clinical social worker at Brookline Community Mental Health Center, which treats students referred from the town’s school district.

Rosing and other mental health specialists said it is hard to know whether the number of self-injurers is actually climbing, or whether the apparent increase is fueled by greater awareness of the problem among clinicians and teachers, coupled with growing social media focus on celebrity self-injury stories.

Much is still not known about the disorder, which has been traced to ancient times, however most specialists accept the definition used by the International Society for the Study of Self-Injury. The society describes it as a deliberate, self-inflicted destruction of body tissue without suicidal intent and for purposes not socially sanctioned. Tattoos and body piercings, for instance, are not considered self-injury.

There has been much debate among mental health specialists over whether self-harm is an illness unto itself, or whether the behavior is a symptom of other health problems, such as depression, anxiety, or borderline personality disorder. Researchers who specialize in this field say fear of litigation from studying such dangerous behavior if a subject harms him or herself, and a lack of consensus about whether self-injury is a distinct illness or merely a behavior on a suicide continuum, have stymied progress on understanding the phenomenon.

Scientists say that most who self-harm are not trying to kill themselves, but instead are typically searching for a way to relieve anxiety, similar to the way some abuse alcohol or prescription sedatives to cope with anxiety, depression, or other mental health problems. Yet new research of college students finds that often the behavior is a sort of gateway to suicide, lowering the threshold to taking the next step.

Cornell University researcher Janis Whitlock and colleagues tracked 1,466 students at five US colleges in the Northeast and Midwest and found that those who had self-injured were roughly three times more likely to attempt or consider suicide. Students with a history of more than five self-injuries were four times more likely, according to the study published in the Society for Adolescent Health and Medicine.

Self-injury “allows them to practice hurting their body,” said Whitlock, a scientist at Cornell’s Bronfenbrenner Center for Translational Research.

Scientists long thought that females were more likely to injure themselves than males. More recently, research has indicated that boys may be nearly as likely to engage in self-harm but have remained in the shadows because they typically do not end up in treatment.

Whitlock’s earlier research of college students found that, on average, those who self-harmed started around age 15, a mercurial time when hormones are raging and brains are still developing.

Whitlock has found that most people who injured themselves ultimately found other ways to cope with their stress and depression and stopped the behavior in one to five years.

“It’s pretty short-lived for a lot of people,” Whitlock said. “But for some people it becomes the dominant method of coping with stress. Then it’s much harder to stop.”

Scientists long thought that females were more likely to injure themselves than males. More recently, research has indicated that boys may be nearly as likely to engage in self-harm but have remained in the shadows because they typically do not end up in treatment.

Alec L. Miller, chief of child and adolescent psychology at Montefiore Medical Center in New York, said cutting, scratching, and other self-harm behaviors appear to release opioids, natural substances that block pain and have a general calming and anti-depressive effect.

Miller and a colleague are known for adapting a type of psychotherapy known as dialectical behavior therapy, or DBT, for treatment of children and adolescents. DBT, regarded as one of the few treatments that has shown success in combating self-injury behaviors, combines Buddhism’s mindfulness with cognitive behavior therapy in a program that teaches coping and communication skills.

Patients first learn to turn to a specific activity, such as holding an ice cube, listening to music or shooting a basketball, when they get the urge to harm themselves. The months-long treatment then focuses on learning to identify and change negative and destructive thought patterns.

One mystery of this secretive disease is how young people first discover that cutting or burning themselves can be soothing. Long before social media — before there were online support groups and celebrity self-injury stories percolated on the Internet — Miller and others were encountering patients who injure themselves.

“Often they learned by complete accident, banging into something like a coffee table that served some distraction and relief from their psychic pain,” Miller said.

Julie, the nursing student, said she remembers the urge started 18 years ago when she was 17, hospitalized for depression, and she saw another patient with cuts on her body who had been harming herself. Depressed and distraught over her parents’ messy divorce, Julie decided to try it.

“I hated myself and was so unhappy,” she said. “I would feel very numb at times and not feel anything. I was really depressed, and cutting would be a way for me to feel.”

For parents, teachers, and others who may discover a child injuring herself, it’s important not to overreact, specialists say.

“Your reaction can exacerbate the very problem we are trying to help, and they may be more ashamed and disgusted by themselves and do it more,” Miller said.

Instead, he said, stay calm, and let the child or teen know you want to help.

Julie received counseling, including DBT, for years, and it helped for periods of time. But it wasn’t until last year, when she completed a different 16-week program, that things clicked. It involved cognitive restructuring for post-traumatic stress disorder that helped her reframe distorted, negative self-images into more productive thinking.

Julie aims to complete nursing school in April. Her goal is to care for patients who are suicidal.

“When patients say, you don’t know what I am experiencing, I can say, ‘I, too, have been there,’ ” Julie said. “As a nurse I would hope that I could share my experiences, in appropriate circumstances, because I am not ashamed of it. My goal is to bridge the two worlds.”

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